Composite grafts are mainly used in complex nasal reconstructions, such as severe alar retraction or columellar defects, especially in revision cases. Success depends on precise surgical planning and a deep understanding of nasal anatomy, focusing on expanding the internal lining and achieving tip and alar contour. Key to graft survival are a clean, sharply debrided recipient bed and preserving the cartilage’s perichondrium to promote revascularization. Emerging strategies like hyperbaric oxygen therapy further enhance graft success by improving vascularization and reducing edema.